Franco DeNardi

The normal esophagus.

The diagnosis of diseases affecting the esophagus frequently depends on a knowledge of the normal anatomy and histology of the esophagus. This paper describes and relates normal esophageal gross and histological features to pathological conditions affecting the esophagus. Special attention is given to the problems of diagnosis encountered when confronted with mucosal biopsy specimens from the gastroesophageal junction.

The cluster-randomized Quality Initiative in Rectal Cancer trial: evaluating a quality-improvement strategy in surgery

Background: Following surgery for rectal cancer, two unfortunate outcomes for patients are permanent colostomy and local recurrence of cancer. We tested whether a quality-improvement strategy to change surgical practice would improve these outcomes. Methods: Sixteen hospitals were cluster-randomized to the intervention (Quality Initiative in Rectal Cancer strategy) or control (normal practice) arm. Consecutive patients with primary rectal cancer were accrued from May 2002 to December 2004. Surgeons at hospitals in the intervention arm could voluntarily participate by attending workshops, using opinion leaders, inviting a study team surgeon to demonstrate optimal techniques of total mesorectal excision, completing postoperative questionnaires, and receiving audits and feedback. Main outcome measures were hospital rates of permanent colostomy and local recurrence of cancer. Results: A total of 56 surgeons (n = 558 patients) participated in the intervention arm and 49 surgeons (n = 457 patients) in the control arm. The median follow-up of patients was 3.6 years. In the intervention arm, 70% of surgeons participated in workshops, 70% in intraoperative demonstrations and 71% in postoperative questionnaires. Surgeons who had an intraoperative demonstration provided care to 86% of the patients in the intervention arm. The rates of permanent colostomy were 39% in the intervention arm and 41% in the control arm (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.63–1.48). The rates of local recurrence were 7% in the intervention arm and 6% in the control arm (OR 1.06, 95% CI 0.68–1.64). Interpretation: Despite good participation by surgeons, the resource-intense quality-improvement strategy did not reduce hospital rates of permanent colostomy or local recurrence compared with usual practice. (ClinicalTrials.gov trial register no. NCT00182130.)

Telepathology for routine light microscopic and frozen section diagnosis.

Telepathology (TP) uses telecommunication linkages to electronically capture, store, retrieve, and transmit images to distant sites. We assessed the feasibility of a dynamic real-time TP system for light microscopic (LM) diagnosis of anatomic pathology specimens, including frozen sections. Six pathologists, in 2 separate periods, read a set of 160 retrospectively retrieved slides (80 of which were frozen sections) by TP and LM. Reading times were recorded. Diagnoses were compared with the reference diagnosis (established by a group of 5 independent pathologists) and graded on a scale of 0 to 2 (2, correct; 1, incorrect but no clinical impact; 0, incorrect with clinical impact). Overall, LM was more accurate than TP compared with the reference diagnosis (score, 1.68 vs 1.54). There was no difference in accuracy between frozen section and paraffin-embedded tissue. Intraobserver agreement ranged from 82.5% to 88.2%. The average reading time was 6.0 minutes for TP and 1.4 minutes for LM. During the study, reading time decreased for TP but not for LM. These results show that despite marginally lower accuracy and longer reading times, TP isfeasible for routine light microscopic diagnosis, including frozen sections.

The Quality Initiative in Rectal Cancer (QIRC) trial: study protocol of a cluster randomized controlled trial in surgery

BackgroundTwo unfortunate outcomes for patients treated surgically for rectal cancer are placement of a permanent colostomy and local tumor recurrence. Total mesorectal excision is a new technique for rectal cancer surgery that can lead to improved patient outcomes. We describe a cluster randomized controlled trial that is testing if the above patient outcomes can be improved through a knowledge translation strategy called the Quality Initiative in Rectal Cancer (QIRC) strategy. The strategy is designed to optimize the use of total mesorectal excision techniques.Methods and DesignHospitals were randomized to the QIRC strategy (experimental group) versus normal practice environment (control group). Participating hospitals, and the respective surgeon group operating in them, are from Ontario, Canada and have an annual procedure volume for major rectal cancer resections of 15 or greater. Patients were eligible if they underwent major rectal surgery for a diagnosis of primary rectal cancer. The surgeon-directed QIRC interventions included a workshop, use of opinion leaders, operative demonstrations, a post-operative questionnaire, and, audit and feedback. For an operative demonstration participating surgeons invited a study team surgeon to assist them with a case of rectal cancer surgery. The intent was to demonstrate total mesorectal excision techniques. Control arm surgeons received no intervention. Sample size calculations were two-sided, considered the clustering of data at the hospital level, and were driven by requirements for the outcome local recurrence. To detect an improvement in local recurrence from 20% to 8% with confidence we required 16 hospitals and 672 patients – 8 hospitals and 336 patients in each arm. Outcomes data are collected via chart review for at least 30 months after surgery. Analyses will use an intention-to-treat principle and will consider the clustering of data. Data collection will be complete by the end of 2007.DiscussionLower rates of permanent colostomy and local tumour recurrence in the intervention arm would suggest the QIRC strategy is efficacious. The strategy may act as a template for efforts to improve surgical quality in other areas and will contribute to knowledge on influencing surgeon practice.Trial registrationCurrent Controlled Trials ISRCTN78363167

Intra-articular nodular fasciitis of the shoulder: a case report and review of the literature

Nodular fasciitis is a benign proliferation of myofibroblasts usually arising adjacent to the fascia. In this report, we describe a rare case in which nodular fasciitis occurred in an intra-articular location in the shoulder of a 26-year-old man. The mass developed in the subscapularis recess of the shoulder and histological evaluation showed a myofibroblastic proliferation. MRI findings of intra-articular nodular fasciitis are discussed along with a review of previous reports.

Unusual presentation of a dermoid cyst in the ischiorectal fossa. Magnetic resonance imaging and ultrasound appearances

The ischiorectal fossa may give rise to a wide variety of pathological entities, although it is composed of relatively few structures. Developmental cysts are included among the list. Large epidermoid cysts in the ischiorectal fossa have been previously described (Fujimoto et al., Clin Imaging 17:146–148, 1993; Ng et al., Can J Surg 49:435–436, 2006). However, to the best of our knowledge, there is no published case in the English literature of a dermoid cyst within the ischiorectal fossa. Using magnetic resonance (MR) imaging and a subsequent ultrasound-guided biopsy, we were able to offer a focused differential that included a dermoid cyst within the ischiorectal fossa in a 55-year-old man presenting with a painful mass on the buttocks. Hair and fatty components were obtained by targeted ultrasound-guided biopsy. On MR imaging, the mass was seen to be well circumscribed and registered a heterogeneous T1-weighted signal that corresponded to layers of fat and debris on short-tau inversion recovery (STIR) imaging. A well-defined ball of fat was noted centrally within the lesion, with a speckled low T1 and low T2 signal within it. Hair admixed with fat was obtained from it by targeted ultrasound-guided biopsy. There was no enhancement of the lesion after administration of gadolinium. On ultrasound, the lesion was well circumscribed and heterogeneous; the echogenic area corresponded to the fat signal seen on magnetic resonance imaging (MRI). The lower level echoes within the lesion corresponded to the debris seen on MRI. The central rounded area of speckling, registering fine posterior shadowing corresponded to the hairy contents obtained by the targeted ultrasound-guided biopsy. A differential diagnosis of all lipomatous lesions was included in the pre-biopsy report: fat necrosis within a lipoma; well-differentiated liposarcoma; myxoid liposarcoma and dermoid cyst. Histopathological diagnosis following complete surgical resection was that of a dermoid cyst.

Radiology–pathology conference: cutaneous angiosarcoma of the leg

Cutaneous angiosarcoma is a rare aggressive vascular neoplasm with a poor prognosis, seen usually in the elderly population in a background of chronic lymphedema. We present a case of cutaneous angiosarcoma of the leg without any chronic lymphedema with clinicoradiological and histological correlation.